Hanling Steven R, Lagrew Joseph E, Colmenar Derrick H, Quiko Albin S, Drastol Carol A
Departments of *Anesthesia and Pain Medicine, and.
Anesthesiology, Naval Medical Center San Diego, San Diego, California.
Pain Med. 2016 Jul 1;17(7):1337-1342. doi: 10.1093/pm/pnw014.
This study evaluated the efficacy of IV cosyntropin as an alternative to epidural blood patch (EBP) for refractory or severe post-dural puncture headache (PDPH).
Twenty-eight patients were randomized to receive EBP or intravenous cosyntropin after diagnosis with post-dural puncture headache. Efficacy was evaluated immediately after treatment and at 1 day, 3 days, and 7 days following treatment using self-reported verbal reported scores for pain and function related to their headache on a 10-point scale using two-way repeated measures analysis of variance (ANOVA) with multiple comparisons.
Baseline information for the control and study cohorts showed no difference based on intent to treat analysis. EBP showed significant improvement over cosyntropin at day 1 (P < 0.001) for VRS pain and function scores; however, cosyntropin demonstrated similar efficacy to EBP immediately after treatment and days 3 and 7 post treatment (respectively, P = 0.459, P = 0.391 and 0.925 for pain and P = 0.189 and 0.478 for function). Treatment effects remained at day 1 after multivariate analysis (P < 0.001 and P = 0.002 for pain and function, respectively).
It is reasonable to consider IV cosyntropin as the treatment of choice for patients in whom EBP is contraindicated or in austere environments where there is limited or no access to anesthesia trained providers. Future research should compare efficacy and cost of prophylaxis to treatment of PDPH with intravenous cosyntropin and evaluate the most effective dosing regimen, including duration, number, and strength of doses.
本研究评估静脉注射促肾上腺皮质激素作为硬膜外血贴（EBP）替代疗法治疗难治性或严重硬膜穿刺后头痛（PDPH）的疗效。
28例诊断为硬膜穿刺后头痛的患者被随机分为接受EBP或静脉注射促肾上腺皮质激素治疗。治疗后即刻、治疗后1天、3天和7天，采用自我报告的10分制疼痛和头痛相关功能言语报告评分，通过双向重复测量方差分析（ANOVA）和多重比较评估疗效。
基于意向性分析，对照组和研究队列的基线信息无差异。在第1天，EBP在VRS疼痛和功能评分方面比促肾上腺皮质激素有显著改善（P < 0.001）；然而，促肾上腺皮质激素在治疗后即刻以及治疗后第3天和第7天显示出与EBP相似的疗效（疼痛方面分别为P = 0.459、P = 0.391和0.925，功能方面分别为P = 0.189和0.478）。多变量分析后，治疗效果在第1天仍然存在（疼痛和功能方面分别为P < 0.001和P = 0.002）。
对于EBP禁忌或处于麻醉专业人员有限或无法获得的严峻环境中的患者，考虑将静脉注射促肾上腺皮质激素作为治疗选择是合理的。未来的研究应比较静脉注射促肾上腺皮质激素预防和治疗PDPH的疗效和成本，并评估最有效的给药方案，包括给药持续时间、次数和剂量强度。
